Updated: 12/31/2021

Sexually Transmitted Infections (STIs)

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  • Overview
    • STD's are one of the most common gynecologic ER presentations
    • All sexually active partners should be screened for STDs
    • Risk factors incude
      • multiple sexual partners
      • unprotected sexual intercourse
      • young age at first intercourse
      • men who have sex with men
    • Common presentations are
      • ulcerations of the vulvovaginal region
      • abnormal vaginal discharge
      • inguinal rashes
      • inguinal lyphadenopathy
      • abdominal pain
    • 25-50% have multiple genital tract infections
      • Disease
      • Introduction
      • Presentation
      • Evaluation
      • Treatment
      • Primary syphilis
      •   Caused by Treponema pallidum (spirochetes)
      •  Appears in 2-10 weeks
      • Painless genital ulceration (chancre)
      • Dark field microscopy, VDRL/RPR (a rapid but nonspecific screening test), and/or a FTA-ABS (specific and diagnostic, the gold standard)
      • Penicillin
      • Secondary syphilis
      • Caused by Treponema pallidum (spirochetes)
      •   Appears 1-3 months after primary infection
      •   Maculopapular rash on palms and soles, fever, headache, and generalized lyphadenopathy
      •   Condylomata lata (moist lesions on the genitals which are highly infectious)
      •  -
      • Penicillin
      • Tertiary syphilis
      • Caused by Treponema pallidum (spirochetes)
      •   Aortic aneurysm and aortic regurgitation
      •   Granulomatous gummas of the CNS, heart and great vessels
      •  -
      • Penicillin
      • Gonorrhea
      • Caused by Neisseriae gonorrhoeae
      •   Dysuria, urinary frequency, and purulent yellow-green discharge
      •   May progress to PID, high rate of coinfection with with chlamydia
      •   Can cause proctitis in the setting of anal intercourse 
      • Evaluation should include cervical and urethral cultures for chlamydia and gonorrhea
      • Clean catch urine culture to rule out UTI
      • Saline/KOH/Gram stain of vaginal discharge
      • All sexually-active women 24 years of age or younger should be screened 
      •   Ceftriaxone, also treat for presumed chlamydia infection
      • If urethritis is refractory to azithromycin, consider Trichomonas and treat with metronidazole 
      • Chlamydia 
      • Caused by Chlamydia trachomatis serotypes D-K
      •   Often asymptomatic, but may cause dysuria, cervicitis, PID, lymphogranuloma venereum, or infertility
      • Chlamydia antigen test
      • All sexually-active women 24 years of age or younger should be screened 
      •   Tetracycline/doxycycline, azithromycin for cervicitis
      •   Use erythromycin base or amoxicillin in pregnancy
      • Do not need to routinely treat for presumed gonorrhea infection, but should in patients with confirmed gonorrhea or high risk patients
      • Venereal warts (condylomata acuminata)
      • External lesions associated with HPV 6,11, endocervical warts caused by HPV 16, 18, 31, 33. Transmitted sexually and have a incubation period of 1 to 6 months
      •   Painless, soft, fleshy, "cauliflower like lesion"
      •   Lesion can be on the vulva, vaginal wall, the cervix, and the perineum
      • Biopsy lesion with 5% acetic acid to detect condylomata acuminata
      •   No treatment is satisfactory. Relapse is frequent and requires retreatment
      •  Treatment modalities include podofilox (an antimiotic), cryotherapy, laser surgery, or electrocauterizations, and biopsy, imiquimod (interferon inducer) are widely used but require multiple applications and frequently fail
      • Presence during pregnancy does not require cesarian section
      • Herpes
      • Caused by HSV-2
      •   Parasthesias and burning followed by painful vesicles and ulcerations
      •   In primary infections patients may present with fever, malaise, and adenopathy
      • Tzanck smear for lesions suspicious of HSV
      • Topical acyclovir ointment during flare-up, oral acyclovir to decrease rate and severity of recurrence
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(M2.ID.12.4) A 21-year-old man presents to the emergency room complaining of pain upon urination and a watery discharge from his penis. It started a few days ago and has been getting progressively worse. His temperature is 98.0°F (36.7°C), blood pressure is 122/74 mmHg, pulse is 83/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for a tender urethra with a discharge. Gram stain of the discharge is negative for bacteria but shows many neutrophils. Which of the following is the most likely infectious etiology of this patient's symptoms?

QID: 102806

Chlamydia trachomatis

33%

(6/18)

Escherichia coli

6%

(1/18)

Neisseria gonorrhoeae

56%

(10/18)

Staphylococcus saprophyticus

0%

(0/18)

Trichomonas vaginalis

6%

(1/18)

M 6 E

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